Spinal cord monitoring with myogenic motor evoked potentials: early detection of spinal cord ischemia as an integral part of spinal cord protective strategies during thoracoabdominal aneurysm surgery.
Spinal cord ischemia during resection of thoracoabdominal aortic aneurysms (TAA) can result in lower limb neurological deficits. Spinal cord monitoring can only improve outcome if ischemia is detected before irreversible damage has occurred and protective measures are readily available. Monitorin( spinal cord function with motor evoked potentials (MEPs) is a relatively new technique. With MEP. recorded from the muscle (myogenic MEPs), the vulnerable spinal motoneuronal system is exclusively monitored and ischemia is detected within minutes. Using a strategy aimed at maintaining and restoring spinal cord blood supply (distal aortic perfusion, sequential aortic clamping, and selective segmental artery reattachment), early detection of ischemia allows protective measures to be applied and adjusted immediately, ie, reattaching or safely ligating intercostal arteries, increasing proximal o distal aortic pressures as required, or inducing hypothermia. Recent improvements in the technique fo eliciting myogenic MEPs include multi-pulse stimulation paradigms and the use of a circumferentia cathode. This results in robust and reproducible signals, which are less susceptible to anesthetic interference and allow the use of a constant level of neuromuscular blockade. In conclusion, monitoring myogenic MEPs during a TAA repair has become clinically feasible. The fast detection of spinal cord ischemia allows timely guidance of protective measures.
de Haan
P
P
Department of Anesthesiology, Academic Hospital, University of Amsterdam, The Netherlands.
Kalkman
C J
CJ
Jacobs
M J
MJ
D000818:Animals; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D019054:Evoked Potentials, Motor; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis* / Q000517:prevention & control; D007511:Ischemia / Q000175:diagnosis* / Q000517:prevention & control; D016343:Monitoring, Intraoperative / Q000379:methods*; D010264:Paraplegia / Q000517:prevention & control; D013116:Spinal Cord / Q000098:blood supply*